How Did Bennet Omalu Make His Money
How the Discovery of CTE Shifted Thinking Behind Concussion Protocol
When Bennet Omalu, MD, identified a degenerative brain disease in NFL players, it shifted the worlds of both sports and neurology.
Bennet Omalu, MD, MBA, MPH, a Nigerian-born forensic pathologist and neuropathologist, brings an almost sacred reverence to his work. His respect toward lifeless bodies is rooted in his medical training, his deeply held Christian beliefs, and his innate compassion, arising from a childhood marked by violence and deprivation following the civil war of the late 1960s and early 1970s in his native country. "Dead people are my patients," Dr. Omalu says. "I regard them as human beings who must be treated with dignity." He begins an autopsy by introducing himself to his patient as any other doctor would. "I look at the face and quietly, silently speak to that person."
It was in that spirit that Dr. Omalu, then a junior pathologist at the Allegheny County medical examiner's office in Pittsburgh, began an autopsy on a Saturday morning in September 2002. The patient on the table was Mike Webster, a former center for the Pittsburgh Steelers. After an illustrious career with the NFL, Webster's life had spun into a maelstrom of neuropsychiatric problems, including depression and difficulties with memory and judgment. He had died of a heart attack, a cause of death that didn't make sense to Dr. Omalu, who wondered how a once highly successful man in his early fifties had seemingly gone crazy. "Mike, I think something is wrong, and I need to examine your brain," Dr. Omalu recalls saying to the body.
Webster's brain looked normal on the outside, so Dr. Omalu had it preserved and sliced onto slides that could be examined later under a microscope. He believed that Webster's remains would speak to him. But few—including Dr. Omalu—iwere prepared for what Webster had to say.
Tangles of Tau
Under the microscope, Webster's brain was marked by abnormal, tangled accumulations of a protein called tau that had damaged large numbers of brain cells. Tau is associated with various forms of dementia, "but these abnormalities were not something I thought I should be seeing in a 50-year-old man," Dr. Omalu says. Academic colleagues in neurology and neuropathology at the University of Pittsburgh agreed that the tau pattern was highly unusual and eventually co-authored a peer-reviewed journal article about the case with Dr. Omalu.
A similar condition, called dementia pugilistica, had been described before in boxers who routinely sustained blows to the head, says Dr. Omalu. "Nobody had made any significant link to other contact sports," Dr. Omalu says. To emphasize that the disease may be more than just a boxing condition, Dr. Omalu borrowed a different term he'd found buried in the medical literature: chronic traumatic encephalopathy (CTE). The title of the resulting paper, published in Neurosurgery in 2005, was a bombshell: "Chronic Traumatic Encephalopathy in a National Football League Player."
Stirring Debate
The findings of Dr. Omalu and his colleagues, and the resulting controversy, have been covered in numerous books, including Dr. Omalu's memoir, Truth Doesn't Have a Side (HarperCollins, 2017), and Concussion by Jeanne Marie Laskas (Random House, 2015), the latter inspiring a 2015 movie by the same name starring Will Smith as Dr. Omalu. Initially, the NFL dismissed and even attacked the findings, along with subsequent reports from Dr. Omalu and his colleagues of other dead former NFL players who were found to have CTE. "A letter from members of the NFL committee on minor head injury demanded that we retract our findings," says co-author Steven T. DeKosky, MD, FAAN, now Aerts-Cosper Professor of Alzheimer's Research and deputy director of the McKnight Brain Institute at the University of Florida in Gainesville. The researchers stood their ground.
"That landmark paper opened the door to a discussion about brain injury that needed to be had," says Tad Seifert, MD, director of the Norton Healthcare Sports Neurology Program in Louisville, KY, and head of the National Collegiate Athletic Association (NCAA) Headache Task Force. "Many considered CTE to be limited to the world of boxing. That was far from the truth."
Battered Brains
Since then, CTE has been established to be a progressive, degenerative brain disease associated with head trauma. It's not limited to football or boxing. The condition has been found in athletes who played soccer, ice hockey, rugby, mixed martial arts, and even BMX bike riding, Dr. Seifert says. "Outside of sports, CTE has also been reported in military personnel, particularly those exposed to blast injuries," he says. "We even see it in individuals previously exposed to domestic violence. It's potentially a problem anywhere an individual has been exposed to head trauma."
Although preliminary evidence suggests that imaging technologies may be able to detect CTE in living people, the only proven way to diagnose the condition at this time is through an autopsy, says Dr. DeKosky. During life, however, CTE can produce a range of neurologic symptoms, including depression, memory loss, confusion, impaired judgment, impulse control problems, aggression, parkinsonism, and eventually progressive dementia. Some people with CTE have committed suicide.
Symptoms generally go unnoticed until years or even decades after the brain trauma occurred or the person has stopped playing sports. But CTE has been documented in people as young as 17, according to a 2016 study published in JAMA Neurology. Symptoms can be managed, but the condition itself can't be cured. "Minimizing the risk and prevalence of brain injury becomes a fundamental public health question," Dr. Omalu says.
A New View of Brain Injury
Increased awareness of CTE has propelled new research, in part because concerned players and their families have donated the brains of at-risk people to experts like Dr. Omalu or a team of researchers led by Ann McKee, MD, professor of neurology and pathology, at the Boston University (BU) Chronic Traumatic Encephalopathy Center, which established a brain bank now numbering more than 600 specimens.
"What we've learned is that overall exposure to brain trauma increases the risk of CTE more than diagnosed or self-reported concussions," says Chris Nowinski, PhD, co-founder of BU's CTE Center and co-founder and CEO of the Concussion Legacy Foundation. "Evidence suggests that hits to the head that don't cause symptoms or can't be diagnosed with standard tests can still cause brain damage."
Cumulative Damage
The potential dangers of cumulative subconcussive hits—blows that don't cause diagnosable symptoms—are now a major research focus. "A concussion is when a hit to the head results in clinical symptoms," says Amaal Starling, MD, assistant professor of neurology at Mayo Clinic in Phoenix. A blow causes the brain to move within a thin cushion of cerebrospinal fluid, striking the inside of the skull, often multiple times. Symptoms may include headache, dizziness, disorientation, difficulty focusing the eyes, trouble concentrating or remembering, crying easily, feeling anxious, or having sleep problems, Dr. Starling says.
"A subconcussive hit doesn't look like anything," she explains. "By definition, it doesn't produce clinical symptoms, so we don't know how to measure or diagnose it. We can't look at two different subconcussive hits and say, 'That one was dangerous and that one wasn't.' The duration of contact play or exposure to contact sports is the only marker of risk from cumulative subconcussive hits that we have at this time."
That doesn't make concussions unimportant. "If you sustain a concussion, you have probably sustained many more subconcussive blows," Dr. Omalu says.
Football player position may offer an indication of subconcussive risks, according to Frank Conidi, DO, director of the Florida Center for Headache and Sports Neurology and a founding member of the American Academy of Neurology (AAN) Sports Neurology Section. "We seem to see a preponderance of traumatic brain injury in offensive and defensive linemen, linebackers, and running backs," Dr. Conidi says. "These are players who bang, bang, bang all day. It's a suggestive link to what's going on—that the cumulative effects of repetitive head banging can harm the brain."
Questions of Risk
How many blows it might take to trigger CTE is unclear. "Is a thousand hits too many?" Dr. Seifert says. "Five hundred? Fifty? One? We just don't know."
Dr. Omalu objects to the idea of thresholds. "Doctors don't say it's okay to smoke two to three cigarettes a day—they say stop smoking," he says. "It's the same here. There is no safe blow to the head."
Some experts are more circumspect, partly because not all people with a history of head trauma develop CTE symptoms. "In the literature that looked at boxers, about 17 percent had this disorder," Dr. DeKosky says. "How much that applies to football, we're not certain. But it suggests that not everybody gets this and, in fact, the majority of people don't."
So far, cases reviewed from brain banks have revealed that all brains diagnosed with CTE were in subjects who had a history of repetitive traumatic brain injury, Dr. DeKosky says. Experts like Dr. Seifert and Dr. Conidi suspect that some people may be genetically predisposed to abnormal tau buildup triggered by head trauma.
Still, the research in football players has not been reassuring. A 2017 study of Boston University data published in the Journal of the American Medical Association found CTE in 110 of 111 pro players' brains. It also found the disease in 48 of 53 college players and three of 14 high school players.
Dicing the Data
Some researchers say such data are compelling but not definitive. "In science, we try to have controls and recruit randomly for studies," Dr. Conidi says. "Research [on CTE] to date hasn't been random. It's been people calling Dr. Omalu or Boston University and saying, 'I want you to have my brain.'" Such volunteers often have symptoms, boosting the chances that investigators will find abnormalities and potentially skewing their conclusions, says Dr. Conidi.
Researchers such as Drs. DeKosky, Conidi, and Seifert emphasize that there's an ongoing need for prospective and longitudinal studies. These would follow random players over time and observe who does and does not develop CTE symptoms or have evidence of the disease in the brain. Comparisons could then be made between players with different outcomes and with people in the general population or those not exposed to head trauma. "It's likely that there are not only different thresholds of recurrent blows to the head, but that genetic factors affect resistance or vulnerability to developing CTE," Dr. DeKosky says.
"We've learned that the average person not living a life where he or she is getting hit in the head is not at risk for CTE," Dr. Nowinski says. "But a small subset of athletes taking thousands of blows a year, plus military veterans and victims of abuse, may be vulnerable populations."
Safeguarding Children
A sea change in approaches to head trauma has taken place to reduce the risks to these vulnerable populations, especially children. "I would argue that we know enough not to have kids getting hit in the head on purpose before high school," Dr. Nowinski says. Dr. Omalu draws the line at age 18.
A 2018 Boston University study of 246 deceased amateur and professional football players published in the Annals of Neurology found that among 211 players who were diagnosed with CTE, the earlier they had begun playing the game as youngsters, the earlier they developed cognitive and behavioral or mood symptoms as adults. Beginning play before age 12 was associated with developing symptoms 13 years earlier, though age of play was not linked to disease severity.
"One of the big misconceptions is that helmets prevent injury, and that is certainly not the case," Dr. Seifert says. "They prevent skull fracture and severe trauma but provide minimal if any protection against brain injury." For more meaningful brain protection, he cites good playing technique in football, such as keeping the head up so that players can see what they're hitting or what's hitting them. "Some evidence suggests that building neck strength can help minimize risk of brain trauma by reducing head movement during impact, especially when an athlete can anticipate a collision," Dr. Seifert says.
Protecting All Players
A key focus has been removing players from the field immediately after a concussion to reduce second concussion risks, which are amplified in an already-injured brain. "In the past, the protocol was to ask, 'Are you okay? What's your name? How do you feel?'" Dr. Starling says. "But if they're concussed, they're confused. They'll say, 'I'm fine,' not because they're trying to lie or don't want to reveal symptoms, but because it's the easiest thing to say."
More objective protocols not only allow for better evaluations, they also help to address the fact that some players may try to minimize any symptoms or lie about them. "No kid wants to come out of the game when he's earned a place on the field," Dr. DeKosky says. Sideline protocols now rely on recording neurologic measures before an athletic season begins, providing a baseline for later injury assessment. But some protocols can be scammed. "Players will deliberately blow the baseline test," Dr. Conidi says. "In many cases we'll see players test better after a concussion than before." A harder-to-fool screening tool called the King-Devick test, which assesses vision, language, and attention performance—often disrupted in a concussion—is now gaining adherents, Dr. Starling says. "But the best way to assess a player is with a comprehensive concussion-focused neurologic history and exam," Dr. Conidi says.
Perhaps the most meaningful change has been one of attitude. "The way a concussion was described in the past was, 'You got dinged,' or, 'You got your bell rung,'" Dr. DeKosky says. "Now, coaches say a player has to come out. That's a huge difference. We accept broken bones or wrecked knees without much of a squawk. But the brain is now seen as different."
Neurology at the Forefront
Greater attention is also being paid to what happens after a concussion. Neurologists in burgeoning concussion programs across the country now routinely manage return-to-play protocols that don't allow athletes back on the field for full-contact practice or games until they've recovered to baseline measures and exhibit no symptoms either at rest or with progressively more demanding physical and mental activity. Return-to-play protocols use non-contact physical activity for rehabilitation from concussion.
"A small number of neurologists have always been involved with sports and sports medicine, but they were a small minority," Dr. Seifert says. "Now the field is growing tremendously."
When Dr. Conidi started the AAN's Sports Neurology Section in 2008, he recalls five sports-related research posters at the organization's annual meeting. "Today it's more like 500," he says. "Dr. Omalu finding that first patient has spawned a whole new generation of neurologists who are interested in this."
Widening the Scope of CTE
Dr. Omalu is contemplative after being in the crosshairs of the sports world and the limelight of Hollywood. "If I hadn't met Mike Webster, I would have lived a peaceful, quiet life," he says. "That was taken away from me. Having said that, people have come to me and written letters saying, 'Bennet, whatever your experiences, you've enhanced lives in ways you don't realize.' Science and faith both search for truth. The more you gain knowledge, the more you discover so much you didn't know."
Now a clinical professor of medical pathology and laboratory medicine at the University of California, Davis, Dr. Omalu is studying how CTE from brain trauma early in life may factor into criminality, "especially in young people who join gangs or are repeat offenders," he says. He anticipates that more parents and athletes will decide against participating in football due to its inherent risks.
"We need to reduce damage and be looking for a pharmaceutical agent that could slow CTE progression," Dr. Omalu says. "Biomechanical solutions like better helmets are not the answer."
Seeking Truth
A scene early in the movie Concussion shows forensic pathologist and neuropathologist Bennet Omalu, MD, played by Will Smith, driving a car as the reflection of an airliner passes across the windshield. "For most people this meant nothing," Dr. Omalu writes in Truth Doesn't Have a Side: My Alarming Discovery about the Danger of Contact Sports (HarperCollins, 2017). "To me, I knew this was an acknowledgment of how I had never wanted to be a doctor. I had wanted to be an airline pilot."
But fate—more precisely, God—intervened at numerous points in Dr. Omalu's life, he says, calling him to enter medicine, immigrate to the United States, specialize in pathology, and be on duty when the body of NFL player Mike Webster was brought to the Pittsburgh coroner's office where Dr. Omalu was working.
Part memoir and part expose, the book—newly released in paperback—recounts Dr. Omalu's journey from a childhood in Nigeria, where the Nigerian Civil War, also known as the Biafran War, of the late 1960s and early 1970s, made life dangerous and difficult for his family, through bouts with depression and self-doubt, and on to America, where he idealized fair play and respect for truth.
Dr. Omalu's finding of chronic traumatic encephalopathy (CTE) in Webster's brain and his subsequent battles with forces aligned with the NFL over the condition's nature and magnitude are portrayed partly as a loss of innocence. "I assumed many of those connected with football would be anxious to know more, since I also assumed they surely had the players' best interests at heart," Dr. Omalu writes. "Yes, I was young and very naive."
The book builds on heightened interest in traumatic brain injury in light of subsequent research and public attention spurred by numerous books and documentaries on the subject as well as the movie Concussion.
"May we always have the grace and wisdom to know when we are called to stand by the truth, to fight battles in defense of the truth and light, no matter how insignificant or inconsequential we may think our lives are," Dr. Omalu writes.
Free Concussion Resources Online
The American Academy of Neurology (AAN) offers a wealth of free resources on sports concussion at AAN.com/concussion to help doctors, athletes, parents, and coaches better understand, prevent, identify, diagnose, and treat the condition.
Tools include a checklist describing signs of concussion that a person can either observe directly or discern from things an athlete with a potential traumatic brain injury may say. The one-page checklist also includes guidelines on immediate actions to take if an athlete has a head injury and recommendations for seeking further care from a licensed health care provider. A downloadable Concussion Quick Check app from Google Play or the Apple App Store is available for mobile devices.
Other free resources include an infographic, videos, and links to further information such as AAN evidence-based practice guidelines, which are summarized for clinicians, patients and families, and coaches and trainers. A section for coaches and trainers features links to training resources or best practice recommendations from the Centers for Disease Control and Prevention, the University of Michigan, and the National Collegiate Athletic Association.
The site also provides the AAN's position statement on sports concussion and a variety of other papers, statements, press materials, and opportunities for education.
Web Extra
Read more about NFL rule changes and concussion protocols.
How Did Bennet Omalu Make His Money
Source: https://www.brainandlife.org/articles/when-bennet-omalu-md-identified-a-degenerative-brain-disease-in/
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